- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.51 / $794.51 / $794.51
| Professional | | $794.51 | $794.51 | $794.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,072.41 / $1,072.41 / $1,072.41
| Facility | | $1,072.41 | $1,072.41 | $1,072.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $668.63 / $668.63 / $835.78
| Professional | | $668.63 | $668.63 | $835.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,072.41 / $1,072.41 / $1,072.41
| Facility | | $1,072.41 | $1,072.41 | $1,072.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.47 / $668.63 / $835.78
| Professional | | $416.47 | $668.63 | $835.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $279.87 / $384.44 / $897.02
| Professional | | $279.87 | $384.44 | $897.02 |